Crowdsourcing is Acceptable to Develop Pre-Exposure Prophylaxis Promotions in Alabama: A Qualitative Study with Sexual Minority Men and Sexual Health Providers

Abstract

Introduction

Crowdsourcing engages the community to create and share solutions; this participatory method could be used to create effective pre-exposure prophylaxis (PrEP) promotions. We explored acceptability of using crowdsourcing to develop PrEP promotions among sexual minority men (SMM) and sexual health providers in Alabama.

Methods

We conducted focus group discussions (FGDs) with SMM and interviews with sexual health providers with guides grounded in the Theoretical Framework of Acceptability. We employed thematic analysis through deductive and inductive coding.

Results

Ten SMM (60% Black, 50% younger than 30 years) participated in FGDs, and six providers completed interviews. We found four themes: 1) Personal identity and background inform the participation and products of crowdsourcing, 2) SMM and providers are motivated to participate in crowdsourcing, 3) Crowdsourcing participants require resources to effectively engage, and 4) Logistic and social factors are barriers to crowdsourcing participation.

Discussion

Crowdsourcing as a strategy to create PrEP promotions in the Southern United states would be acceptable and feasible in the correct context. These formative, yet novel, findings demonstrate that SMM and sexual health providers would be willing to participate in crowdsourcing events and also provide key insight to design crowdsourcing events.

Plain Language Summary Title

Crowdsourcing to Create PrEP Promotions is Acceptable by Gay, Bisexual, and Other Men Who Have Sex with Men and Sexual Health Providers in Alabama

Plain Language Summary

Crowdsourcing is a way to engage community members to participate in solving problems and sharing the solutions back with the community. Pre-exposure prophylaxis (PrEP) effectively prevents HIV. Crowdsourcing to promote PrEP may be a way to better communicate about PrEP to community members, but we do not know how acceptable this would be the community. This study explores how gay, bisexual, and other men who have sex with men and sexual health providers would feel about using crowdsourcing to promote PrEP. To determine this, we conducted FGDs and interviews with participants. We audio-recorded, transcribed, and studied their answers to understand what were the most important aspects. We found that 1) a person's background influences their participation, 2) community members would be motivated to participate, 3) community members would need resources, like funding or time, to participate, and 4) shame related to sexual health, HIV, LGBTQ+ identity as well as other barriers may prevent some community members from being able to participate. Overall, we found that community members and sexual health providers feel that crowdsourcing could be a good idea to better promote PrEP in the community.

Keywords

HIV HIV prevention health promotion crowdsourcing PrEP

Introduction

HIV continues to impact sexual minority men (SMM) at a higher rate than other communities. Nearly 70% of new HIV diagnoses in the U.S. are among gay, bisexual, and other men who have sex with men.^1,2 Among those, Black and Hispanic/Latino SMM constitute a disproportionate number, especially in the Southern United States (US), which continues to have the highest rate of new diagnoses in the US annually.^1,3,4 HIV pre-exposure prophylaxis (PrEP) is highly effective for all persons, yet the Southern US, a region defined by the Centers for Disease Control and Prevention for states across the southeastern region, only had 39% PrEP coverage in 2024, which is insufficient to meaningfully impact the HIV epidemic, especially among Black and Hispanic/Latino SMM.^5–10

Barriers to PrEP use include structural racism and homophobia, medical mistrust, and stigma surrounding sexual and gender minority identity, sexual health, and HIV in the South.^11–14 Moreover, in the Deep South, more overt racism and homophobia can exacerbate barriers among SMM with intersecting identities, reducing access to care in the Southern US.^15,16 To address these barriers, PrEP promotions need to be culturally sensitive and relevant to engage and empower SMM and reduce stigma, particularly for racial and ethnic minority SMM living in the South. Current PrEP and other HIV prevention services’ messaging is often neither sufficiently informative nor culturally relevant.¹⁷ For example, some existing content to promote PrEP, such as digital advertisements and public health promotions, focused exclusively on young, Black SMM, may be perceived as stigmatizing as the content portrays young, Black SMM as the only group at risk for HIV.^17,¹⁸ Furthermore, Southern SMM at risk for HIV prefer PrEP promotional content that emphasizes cultural relatability (ie, self-identifying, personal messaging) and diversity and minimizes HIV risk and loss-framed messages.¹⁷

Crowdsourcing is an innovative process to solve a problem affecting a community by engaging that community, often non-experts, to create solutions and later sharing solutions back to the larger community.^19–21 Crowdsourcing mirrors many aspects of a user-centered design or human-centered design framework, centering the end-user in the creation of solutions; as a participatory method, crowdsourcing intentionally involves the “crowd” members in creating the solution, expanding and engaging the role of the end-user in the process. Crowdsourcing methods vary as open calls, challenge contests, designathons, and co-creation events, among others. These methods often employ steering committees and judging panels to guide the outcomes. Each method employs different processes with the same fundamental principle: engaging the crowd to solve a problem.^20,22–24

Crowdsourcing has been used effectively to develop high-quality, culturally relevant health content in other contexts, including HIV testing messaging for SMM in China as well as PrEP promotional messaging in high HIV incidence areas outside of the Southern US.^25–28 Additionally, previous findings indicate that the HIV testing messages developed via crowdsourcing for SMM are cost-effective and of comparable effectiveness to standard promotional content developed by health authorities.^25,26 Crowdsourcing could be used to develop culturally tailored PrEP promotions created by, and for, SMM living in the Southern US to improve PrEP awareness and uptake to address disparities.²⁹ However, crowdsourcing has not yet been used to engage SMM living in the Southern US to develop PrEP promotions.³⁰ SMM in the Southern US prefer PrEP promotions that are inclusive for all persons at risk for HIV and center relatability, not fear or risk-based promotions.¹⁷^,31,32 Crowdsourcing could be harnessed to create PrEP promotional content aligned with these preferences and needs, but the acceptability to use crowdsourcing for PrEP promotions in the Southern US is unknown. This study assessed the acceptability of using crowdsourcing among both SMM and sexual health providers in Alabama as a strategy to develop and implement PrEP promotional content that is culturally relevant, empowering, and informative.

Methods

This formative study, conducted from 2022 to 2023, aimed to explore the barriers, facilitators, and other considerations surrounding the acceptability of crowdsourcing open calls to develop PrEP messages, such as advertisements and informational media, for SMM in the Southern US. To determine the acceptability, we conducted both focus group discussions (FGD) among SMM and semi-structured interviews (SSIs) sexual health providers in Alabama. We employed an exploratory, phenomenological lens guided by the Theoretical Framework of Acceptability (TFA). The TFA consists of seven constructs to assess acceptability: affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy.^33,34 Each construct examines a different aspect of acceptability, and we operationalized all constructs of the TFA for this work. Prior to each FGD and SSI, the facilitator explained crowdsourcing in the general context, including the processes and methods of crowdsourcing, as well as in the context of creating PrEP promotional content; participants asked questions to clarify their understanding, and they were reminded that the questions explored the crowdsourcing process. The Institutional Review Board approved this study and all procedures. Each participant provided written informed consent or verbal informed consent (written documentation for verbal consent waived per IRB approval) prior to participation, including data collection and reporting. This study and its reporting adheres to the Standards for Reporting Qualitative Research (see supplemental materials for checklist).³⁵

Focus Group Discussions

To investigate SMM's perceptions, attitudes, and beliefs regarding the acceptability of using crowdsourcing to develop PrEP messages and their participation in crowdsourcing, we conducted two FGDs with a total of 10 SMM. We employed FGD to foster discussion and conversation among participants. Inclusion criteria were SMM ages 18-39 years, who self-reported HIV-negative and spoke English; although there were no race or ethnicity restrictions for enrollment, we aimed to enroll at least 50% Black SMM and 10% Latino SMM, reflecting the current demographics of new HIV diagnoses in Alabama.³⁶ SMM living with HIV or who did not speak English were excluded from this work. We purposively sampled participants from community outreach using flyers, word-of-mouth, and in-person referrals as well as clinical sites and organizations that provide HIV prevention services, ie, local HIV testing and PrEP clinics. We conducted FGDs in-person using a topic guide grounded in the TFA, and we digitally audio-recorded each FGD for verbatim transcription. The supplemental materials include the final FGD topic guide.

Semi-Structured Interviews

We conducted SSI with sexual health providers to explore the acceptability and their interest in participating in crowdsourcing. Specifically, sexual health providers may be engaged to participate as steering committee or judging panel members for challenge contests or open calls or as technical experts in co-creation events. We recruited participants from one HIV clinic through direct outreach. Trained qualitative interviewers with experience in HIV prevention research conducted each SSI using a guide grounded in the TFA with probing as necessary. Interviewers audio-recorded each SSI for verbatim transcription. The supplemental materials include the final SSI topic guide.

Analysis

We uploaded FGD and SSI transcript files into NVivo 14 (Lumivero, Denver, CO, USA) to organize the qualitative analysis. We deductively coded the transcripts with initial codes grounded in each of the seven TFA constructs and subsequently inductively coded the transcripts to allow new codes to emerge. Author KMJ led primary coding with secondary coding by RMG. The coding team met regularly to iteratively revise the codebook; the coding team managed any disagreements through discussion to find shared meaning, identify differences, and reach consensus. We used thematic analysis to develop themes with sub-themes from categories, codes, and sub-codes. We reviewed codes and sub-codes to combine into categories, when possible, to develop the themes and sub-themes mapped to the relevant constructs of the TFA. We employed the TFA, rather than a grounded theory approach, allowing a focused deductive analysis supported by the inductive approach, which helped us to build the themes to answer our research question. After final analysis and discovering no new themes to answer our research question of crowdsourcing acceptability, we determined we had reached thematic saturation through two focus groups and six interviews.^37,38 Supplemental materials include the final codebook.

Results

We completed two focus groups with five participants each (n = 10). The majority of focus group participants reported Black race (60%) and non-Hispanic (90%) ethnicity. Half of participants reported ages from 19 to 29 years old, and 40% reported their age from 30 to 39 years old. Sexual health providers (n = 6) were experienced in managing HIV and sexually transmitted infections in public health and academic medical centers; to preserve confidentiality, we do not report provider demographics. We found four major themes with associated subthemes: 1) personal identity and background guide the participation and products of crowdsourcing, 2) SMM and providers are motivated to participate in crowdsourcing, 3) crowdsourcing participants require resources to effectively engage, and 4) logistic and social factors may prevent crowdsourcing participation. Table 1 provides themes and subthemes mapped to constructs of the TFA with exemplar quotes.

Table 1.

Themes and Sub-Themes Mapped to Theoretical Framework of Acceptability with Exemplar Quotes.

Theme	Sub-theme	Construct	Exemplar quotes
Identity and background inform crowdsourcing participation and the products of crowdsourcing	Both SMM and non-SMM should participate in crowdsourcing and be the audience for crowdsourced promotions.	Affective Attitude, Perceived Effectiveness	I feel as though it should be created by the community, but by the same token, they should have some input from other communities also because the MSM community and the LGBTQ community…it's been decades that we’ve been plagued with this…But it spread to everyone. (FGD1, Participant 5) If we do advertisement or promotion towards everybody as a general population, that would end up helping at-risk closeted gays or LGBTQ individuals…Then you’re able to open up that conversation [with others] of this is what you can do to prevent HIV without it being attached to something that's like MSM related. (FGD1, Participant 2) I don't know if it even needs to just be specifically targeted towards one community…It definitely needs to be something that everybody understands that just because you are sleeping with a woman don't mean you can't catch HIV. (FGD1, Participant 1)
	Non-LGBTQ + providers see their crowdsourcing role as limited to sharing medical expertise.	Affective Attitude, Ethicality	I do feel like my experience would be more limited just because I would only feel like I could really comment on the accuracy of the content from a scientific point of view. I couldn't comment on the acceptability of the content. (Provider 4) Having people affected by something propose solutions seems like a very wise idea, but at the same time we have medical training and a medical background for a reason, so it makes sense to have experts at least review the proposals and hopefully discuss [the content] with [the creators] if questions come up, and kind of coming up with a solution together as a team. (Provider 3)
	Crowdsourcing processes and products should intentionally have diverse representation.	Perceived Effectiveness	If we’re having MSM for example, we also have other groups. Black women and also indigenous people are also at a higher risk for HIV. If we have someone who looks visibly indigenous on a billboard for example, with a PrEP study, link and stuff like that, more indigenous people would be inclined to look at that and say, “Well, I didn’t—I don’t know exactly know what this has to do with me.” (FGD1, Participant 2) A lot of what we do PrEP-wise really centers on urban and suburban communities, and we really forget about rural communities as well as immigrant or migrant communities. (Provider 1)
Motivation to participate in crowdsourcing is strong	SMM want to participate in crowdsourcing and give back to their community.	Affective Attitude	I feel just I can [participate] because I am a member of the community that is heavily affected by it. I personally want to see change in the community. I personally want to see the community get away from the stigma. (FGD1, Participant 1)
Motivation to participate in crowdsourcing is strong	Providers want to participate in crowdsourcing to serve the community while addressing the HIV epidemic.	Affective Attitude	Meeting someone in that community can have a huge impact. I think that is what opens the door to a lot of—especially early career people—to be more open and accepting to taking care of those patients or doing work with that community or whatever it is. Just meeting people that belong to the community and hearing their personal stories can be really impactful. (Provider 5)
Crowdsourcing participants require resources to effectively engage	Community heroes should be involved in crowdsourcing to increase its acceptability and the promotional messaging products’ appeal.	Perceived Effectiveness	If Lady Gaga said go get on PrEP, people are gonna go and get on PrEP. (FGD1, Participant 3) I think it's important to have a community hero, if not already existing. For example, if we’re talking about the LGBTQ community in Birmingham, we need to have someone who is openly gay, bisexual or transgender, who can go out and have these talks and conversations. (FGD1, Participant 2)
	Effective crowdsourcing needs funding to produce and media to share the product.	Perceived Effectiveness	When you were speaking about challenges or problems or creating that, like I think another issue would be having proper funding to make sure that the message could be told correctly. (FGD1, Participant 3) Media of course [would be needed] whether being radio, television, and some type of app because people are on their phones more than anything nowadays. (FGD1, Participant 5)
	Participants may have or may not have sufficient skill-sets to effectively participate.	Self-Efficacy	I work in sales as well, so it's like second nature for me to come up to someone and just get you comfortable with me, and just know how to make it make sense. (FGD1, Participant 1) You have to state the problem as well, especially in a place where they may not be as aware of what the problem is. Assessing the understanding of whoever you’re trying to engage is important, because if you’re talking to someone who doesn’t know that HIV's a problem in their community, why are they going to participate? (Provider 5)
	The expectations of the plan and process of crowdsourcing must be clear to recruit participants.	Intervention Coherence	If you tell them like, “We’re trying to get the community's perspectives on this, this, this, and this. You will be here for this long. You will or will not be compensated for your time. It's a safe space.” Setting the expectations of what it would be, I think, makes it less intimidating. […] The key components to making it approachable and feasible for people are explanations as to what is being asked of them and assurance that it's a safe space for this community. (Provider 5)
Logistic and social factors are barriers to crowdsourcing participation	The time required to crowdsource must be convenient, organized, and reasonable for participation.	Burden, Opportunity Costs	You could condense it into a food festival or something like that, where somebody could stop by. You talk to them for, like, 10 minutes and get what they think, their ideas on it. Get them engaged that way because not a lot of people are gonna come and sit for an hour. (FGD2, Participant 2) Just like everyone else, it really would depend on what my role is and what is needed from me. I can’t really tell you what my challenges would be not knowing exactly what the expectations of me would be. (FGD1, Participant 3)
	Compensation for the time spent on crowdsourcing could be necessary for participation.	Burden	If I choose to not go home watch a movie or come here and make some money, yeah, I wanna make some money. But also, like, I wanna help a cause that I'm participating in as well. But the money is also an added bonus, too, as well. (FGD2, Participant 1)
	Comfort discussing HIV as part of crowdsourcing may affect willingness to participate in crowdsourcing.	Ethicality, Affective Attitude	I would say within providers, there's probably early adopters, late adopters, and everything along the middle. If they’re an early adopter or just in the contemplated phase, I think that they, depending on the topics around the discussion, they could be offended. Especially if certain people on the panel were very open and sharing. (Provider 2) Me [now] being 26, at 18, you couldn't have came and talked to me about PrEP. (FGD2, Participant 4)
	Privacy and stigma concerns for both SMM and/or providers surrounding sexual health/HIV may preclude acceptability.	Affective Attitude, Opportunity Costs	Putting my name on it [would prevent me from participating]. […] I don't want anybody to know what I'm doing. I don't have to sign my name off for people to know I did it. (FGD2, Participant 4) The blame is gonna be put back to the people who are in the video promoting…And that may put even more of a negative stigma on, so people won’t wanna use it. (FGD1, Participant 5) [A burden may be that people feel] like, “Oh, I don’t wanna do this, people gonna think that I’m this, or people gonna think that”—you know, just like some people don’t even wanna come to the [HIV Clinic Building]. […] That's just the stigma around it. (FGD1, Participant 1)

PrEP, pre-exposure prophylaxis; SMM, sexual minority men; FGD, focus group discussion.

Theme 1: Identity and Background Inform Crowdsourcing Participation and the Products of Crowdsourcing

Both SMM and providers felt that identity and background were crucial in determining who should be involved in crowdsourcing for PrEP promotions, how they should be involved, and the implications of their involvement on the produced message. Participants expressed that identity is fundamentally tied to the participants’ lived experiences, knowledge, and authenticity, but sexual minority and racial or ethnic identity overrepresentation may cause stigmatization of the produced messages, particularly in the Southern US. Having a diverse representation of identities in the crowdsourcing process, and ultimately the crowdsourced product, will potentially reduce the stigmatization and make the crowdsourcing process itself more acceptable. Furthermore, participants discussed potential merits and consequences regarding whether products of crowdsourcing should be directed solely to SMM or other communities at large.

Participants felt that SMM and racial and ethnic minority persons should be involved in creating more authentic, relevant messages, through crowdsourcing, since the HIV epidemic in the Southern US greatly and disproportionately affects these communities. One participant felt that SMM can “better push [PrEP] out and give you raw emotions” (FGD1, Participant 5). They felt that their identity and the lived experiences of SMM in the South were valuable assets in crowdsourcing for PrEP messaging.

Some participants suggested that non-SMM (eg, cisgender, heterosexual women and men, gender diverse persons) or discreet SMM (SMM who do not openly identify as gay or bisexual but have sex with men) should also still participate in crowdsourcing and should be the intended audience of crowdsourced products for multiple reasons. First, HIV affects many non-SMM in the South, and thus interventions are needed to increase PrEP uptake more generally. Second, if crowdsourcing only involved and addressed SMM, then stigma could cause the crowdsourced message to not be widely acceptable and “would push [others] away” (FGD2, Participant 1). Participants felt that, while crowdsourcing by, and for, SMM was seen as important, it was not acceptable to crowdsource to produce PrEP messages for SMM only. Crowdsourcing to promote PrEP to SMM was not mutually exclusive to promoting PrEP to all persons, and these messages should occur together to improve crowdsourcing's acceptability in terms of affective attitude and perceived effectiveness.

Sexual health providers who are not SMM themselves expressed hesitation about participating in crowdsourcing from ethicality and effectiveness standpoints since they are not the “target demographic” (Provider 4). However, they felt motivated to contribute through their medical expertise. Provider 5 noted, “acknowledging that it's both community-driven but also evidence-driven, I think makes that type of content something that would be a success, because it's community-based [and] they also have people who are knowledgeable about medical safety, who are trained in HIV medicine.”

Identity should also be considered beyond sexual orientation in crowdsourcing, as SMM and providers emphasized the importance of demonstrating diversity in other aspects such as race, ethnicity, and geography to engage subgroups when they see the message and consider relevant cultural contexts (improving perceived effectiveness of using crowdsourcing). As one SMM participant noted, “A gay, Black man is more inclined to listen to another gay, Black man versus anyone else. So, I think if there are more commercials where there are more gay, Black men or even straight, Black men, you know, there are just more Black people expressing that it is okay to protect yourself from HIV, it is okay to take care of yourself” (FGD2, Participant 4).

Theme 2: Motivation to Participate in Crowdsourcing is Strong

Barring competing priorities or barriers to crowdsourcing, there was strong interest and excitement to participate in crowdsourcing for PrEP messages, with varying sources of interest and excitement between SMM and sexual health providers. SMM expressed motivation to participate in crowdsourcing to serve their community through improved community wellbeing and more relevant messages. One participant noted that SMM “are infamously underrepresented and have had their voice taken away,” saying that “I think they would jump at having a say [with crowdsourcing]” (FGD2, Participant 2).

Providers expressed that participating in crowdsourcing through a steering committee or judging panel, primarily focusing on the scientific merits, would be an exciting opportunity to give back to their patient community, as they are “discouraged by new infections” (Provider 4). Additionally, crowdsourcing would serve as a professional development opportunity for providers to get “into a more community space” (Provider 2). Overall, both SMM community members and sexual health providers felt highly motivated to participate in crowdsourcing as an avenue to improve PrEP messaging and increase PrEP uptake.

Theme 3: Crowdsourcing Participants Require Resources to Effectively Engage

Although there was a strong motivation to participate, participants shared that they would require resources to effectively engage in crowdsourcing. These requisite resources included both tangible resources, such as funding and space, and intangible resources, such as HIV and PrEP knowledge.

SMM participants believed that “community heroes” who are well-recognized people in the community, such as community champions and influencers, could be a resource in the promotion to increase the appeal of the message and make it more effective. Participants noted that having such persons involved in the crowdsourcing process will generate more success, thus improving effectiveness of crowdsourcing to produce PrEP promotional content and making crowdsourcing more acceptable. As one SMM participant noted, “We cannot do generalized ads … [people] don’t stop scrolling unless it's someone they recognize, like a face” (FGD1, Participant 2). However, one participant expressed hesitation surrounding the value of community heroes, especially if the hero is not part of the LGBTQ + community themselves. Citing previous PrEP messages that have pictured recognizable figures, they said it will “only work as well as it's been working” (FGD1, Participant 4). SMM participants briefly mentioned that funding would be needed so that “the message could be told correctly” (FGD1, Participant 3) as well as an appropriate medium to convey the crowdsourced message, ie, buying digital ad space because “people are on their phones more than anything nowadays” (FGD1, Participant 5).

One significant intangible resource is knowledge, especially related to HIV and PrEP; participants felt this to be essential to improve their self-efficacy to participate in crowdsourcing, as one participant explained: “If no one understands [HIV as a] problem, then what are we solving?” (FGD1, Participant 2). This FGD participant then explained based on their racial identity, saying that “the Black community understands that economics is a problem, so they are doing things to try to make it not a problem anymore” (FGD1, Participant 2).

Similarly, SMM and providers both emphasized that the existing skillsets from their current work as necessary or relevant to participating in crowdsourcing. One participant mentioned their work in sales when asked if they could crowdsource, saying, “It's like second nature for me to come up to someone and just get you comfortable with me” (FGD1, Participant 1). Relatedly, providers emphasized their medical expertise as a skill set: “I think that my voice has some important pieces that maybe general community members wouldn’t be able to articulate in terms of the medical side of things and the logistics and the realities of what is possible” (Provider 5).

Finally, participants described the importance of understanding the crowdsourcing process to participate and create promotions, in terms of technical clarity of crowdsourcing processes as well as feeling secure in participating in crowdsourcing, as some FGD participants expressed mixed understanding of the process of crowdsourcing. As one participant said, “To some people [crowdsourcing] may be [confusing], but to be able to explain it in an elementary type of way to the people […] if it's broken down to them thoroughly, they can understand it” (FGD1, Participant 5).

Theme 4: Logistic and Social Factors are Barriers to Crowdsourcing Participation

Contrasting the enabling factors of acceptability, participants emphasized the logistic and multi-level, social barriers that may prevent inclusive crowdsourcing participation and reduce the acceptability of crowdsourcing. Both SMM and sexual health providers expressed that “bad timing” (FGD1, Participant 5) or “poor organization” (Provider 1) of crowdsourcing would be both a barrier and a burden to participating in crowdsourcing. Multiple factors would determine the adequate amount of time to participate and appropriate burden, such as the amount of time scheduled in advance, the complexity of crowdsourcing, their passion to participate, or competing priorities. As one SMM participant said:

Somebody like me, who works a full-time job, I wouldn't have that kind of passion [that some have], right? I would do it just because I understand what the need and the cause is, but I'm not gonna say I'm gonna spend two months on it (FGD2, Participant 4).

Aside from the time and organization of crowdsourcing, some SMM participants expressed that fairness in compensation for the time and effort to develop materials, with one participant saying that they “can’t do nothing for free” (FGD1, Participant 1).

Participants discussed how those among their respective communities may have varying beliefs and comfort on HIV prevention and sexual health. Among providers, they suggested that some other providers may be uncomfortable with the topic, with one provider saying, “It's a thing that [some providers] ‘don’t agree with the lifestyle that someone is living.’ All these things are morals that would get in the way of people for sure participating” (Provider 5). SMM focus group participants expressed that some community members may have varying beliefs or comfort discussing PrEP and sexual health, particularly regarding the nature of HIV and the introspection or self-reflection that crowdsourcing may require of participants. As one participant compared their first HIV testing experience to participating in crowdsourcing about HIV and PrEP: “I didn’t wanna go because I was afraid it was gonna be positive” (FGD1, Participant 2). Crowdsourcing may similarly cause discomfort if it's seen as solely an SMM matter, since “anybody that is LGBTQ or relates to that wouldn’t want to have a discussion about LGBTQ matters […] because they don’t want it to be confirmed” (FGD1, Participant 2).

Finally, some SMM participants noted that the participants may not want to participate in crowdsourcing because of the public nature of the messages that will be created, aside from the potentially public crowdsourcing process itself. Specifically, they did not want to be pictured or mentioned personally in the message. Furthermore, there were mixed levels of concern about the loss of privacy with the collaborative nature of crowdsourcing and the sensitive nature of sexual health, but one participant countered by saying their sexual health and behavior can remain private while participating in crowdsourcing: “I don’t have to tell you that I slept with three people yesterday and I was in a threesome this morning, for me to come in and be effective on giving this content” (FGD1, Participant 3). Stigma associated with HIV or sexual identity may lead to some SMM to not want to be pictured in the advertisement, as some people will make assumptions about their HIV status, sexual behavior, or their sexuality, as one FGD participant noted, “[Discreet SMM] may be in fear to do a commercial or anything like that because they’re like, ‘the truth of who I am is gonna come out’” (FGD1, Participant 1).

Discussion

Both SMM community members and sexual health providers generally found crowdsourcing to be acceptable to create PrEP messages. This qualitative work is the among the first to explore how SMM and providers in the Southern US feel about crowdsourcing and can inform design choices to make crowdsourcing acceptable and effective in this context. Furthermore, these findings support existing literature that sexual health stakeholders should consider using crowdsourcing to create authentic, relevant, and inclusive messaging to increase HIV prevention services uptake.^27,39,40

Our data suggest that crowdsourcing for PrEP promotions would be acceptable among SMM in the Alabama and possibly throughout the Deep South. Study participants desired to use crowdsourcing to bring personal experience and cultural relevancy to PrEP promotions through their identity to improve PrEP messaging, indicating a strong affective attitude. This desire to crowdsource is encouraging considering that current PrEP messages, especially public health PrEP campaigns, have fallen short in terms of being sufficiently relevant or informative and perpetuating stigma, particularly among racial/ethnic minority SMM.^41–43 Additionally, considering barriers to PrEP uptake in the Southern US, such as stigma, homophobia, and racism, relevant crowdsourced PrEP promotions may be particularly useful to address these barriers by involving the crowd to create promotions that are culturally relevant and inclusive to overcome stigma, racism, and homophobia, especially in the Southern US where these barriers limit PrEP uptake.^44–47 Our study is the first to explore crowdsourcing among SMM in the Southern US context and aligns with other research on PrEP messages addressing non-SMM and being racially diverse to address stigma associated with SMM and HIV, which seems to be prevalent nationwide.^48–50 Aside from crowdsourcing's perceived effectiveness, these barriers also contributed to concerns about the privacy of crowdsourcing or stigmatization due to crowdsourcing, which further indicate that crowdsourcing's privacy safeguards must be transparent and mutually determined to re-assure potential participants that their information and identity are protected. Different crowdsourcing processes can employ varying levels of anonymity, with these findings suggesting that anonymity during crowdsourcing should be considered in the Southern US context.

Sexual health providers’ affective attitude and perceived effectiveness contribute to their motivation to participate in crowdsourcing through their medical expertise, rather than their own identities as SMM participants shared, has notable implications for organizing crowdsourcing open calls. Providers see PrEP provision as aligned with their clinical responsibility, ie, ethicality, to support patients as they can; thus, willingness to participate in crowdsourcing may be seen as an extension of that helping orientation.⁵¹ The role of providers and the participants’ emphasis on involving non-SMM at-large indicates that, even if the intended problem that crowdsourcing aims to address is low PrEP uptake among SMM, non-SMM allies and community members must be involved in the solution. Furthermore, provider involvement could extend beyond only involvement in judging panels. Provider visibility during the crowdsourcing process could assuage the anticipated stigma that some SMM may perceive from providers.

Crowdsourcing acceptability also includes feasibility concerns, which we considered in the context of crowdsourcing burden and opportunity costs in the TFA. Study participants voiced concerns regarding feasibility, especially in terms of the amount of time involved to participate, modality (in-person vs online), and fairness through potential compensation for time to offset competing priorities. These concerns have been reported in previous literature, which has found that some community participants may prefer an online format for ease or may not engage sufficiently in long-term efforts necessary for crowdsourcing.²¹ Careful design of crowdsourcing processes and events that allow sufficient time and resources such as in-person and virtual modalities, asynchronous involvement, and supporting design and medical expertise will better ensure inclusive engagement by addressing many of these concerns. Crowdsourcing methods are grounded in innovation, so the processes and events can be adapted to best suit the context and crowd.

This study exhibits strengths in its context-specific and theory-guided exploration of the acceptability of crowdsourcing for PrEP messages in the Southern US, providing formative results that will inform crowdsourcing interventions for PrEP promotions. However, the study also has limitations. Our sample was relatively small in terms of SMM (n = 10) and sexual health providers (n = 6); however, we reached thematic saturation in the FGD and SSI. Furthermore, we recruited our SMM sample from a relatively urban and racially and ethnically diverse area, which may limit the generalizability of our findings to other contexts in the Southern US (ie, rural areas). Additionally, our provider sample included only sexual health providers, which might bias towards acceptability for PrEP, sexual health prevention work, and crowdsourcing for PrEP messages, and they noted that some other providers who don’t work in sexual health or in a rural area may be less comfortable participating in crowdsourcing. Crowdsourcing research and implementation in this context must consider the necessary provider stakeholders to engage, such as providers not focused on sexual health. We noted high similarity in themes among SMM FGDs and among provider interviews, as well as the agreement of our findings with the extant literature, encouraging crowdsourcing for intervention implementation. Further research is needed to explore differences in findings based on different promotional contexts (eg, more rural locations) to further investigate the feasibility of crowdsourcing for PrEP messages in the Southern US. Lastly, this work did not include non-English speaking participants, which limits the generalizability into communities who do not speak English with high HIV burden, eg, Hispanic and Latino communities in the Southern US.

Future work will focus on how to effectively conduct crowdsourcing events to promote PrEP, specifically focusing how to engage the community to contribute to crowdsourcing events. Prior work in the mid-Atlantic US demonstrated that crowdsourcing could be feasible, but this may not be generalizable to the Southern US context and should be explored further.⁵² Additionally, we must also focus on how to measure the impact of crowdsourced PrEP promotions on PrEP outcomes, including awareness, uptake, and use. Our work demonstrates that crowdsourcing is acceptable, so this participatory method may be considered beyond creating promotional content for PrEP; for example, crowdsourcing could also be used to support program design among stakeholders, sexual health training, and curriculum development to increase PrEP providers, or refining interventions to improve PrEP provision.

Conclusion

Crowdsourcing to produce PrEP messages is acceptable to the SMM community and sexual health providers in Alabama. These novel findings, for both community members and providers, demonstrate that crowdsourcing to promote PrEP should be pursued in efforts to increase PrEP uptake and combat the HIV epidemic in the Southern US.

Supplemental Material

sj-docx-1-jia-10.1177_23259582251410273 - Supplemental material for Crowdsourcing is Acceptable to Develop Pre-Exposure Prophylaxis Promotions in Alabama: A Qualitative Study with Sexual Minority Men and Sexual Health Providers

Supplemental material, sj-docx-1-jia-10.1177_23259582251410273 for Crowdsourcing is Acceptable to Develop Pre-Exposure Prophylaxis Promotions in Alabama: A Qualitative Study with Sexual Minority Men and Sexual Health Providers by Kevin M. Joseph, Latesha Elopre, Lynn T. Matthews, Barbara Van Der Pol, Joseph D. Tucker and Ronnie M. Gravett in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgements

We would like to thank our study participants, community partners, Tim McWilliams, Michelle Chambers, Bernadette Johnson, and Tammi Thomas for their assistance and guidance during this project.

ORCID iDs

Lynn T. Matthews

Ronnie M. Gravett

Ethics

The Institutional Review Board at the University of Alabama at Birmingham approved this study and all procedures (IRB-300007864). Each participant provided written informed consent or verbal informed consent (written documentation for verbal consent waived per IRB approval) prior to participation, including data collection and reporting.

Authorship Contributions

All authors contributed to the overall study conception and design. KMJ and RMG led data analysis. KMJ led primary manuscript preparation. All authors critically reviewed and made substantial contributions and revisions to the final manuscript. All authors approved the final version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number K23MH126794 (PI, Gravett) and by the National Institute of Allergy and Infectious Disease of the National Institutes of Health under award numbers K24AI143471 (PI, Tucker) and K24AI184259 (PI, Matthews), and the University of Alabama at Birmingham (UAB) Center For AIDS Research CFAR, an NIH funded program (P30 AI027767) that was made possible by the following institutes: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, NIDDK, NIGMS, NIMHD, FIC, NIDCR, and OAR.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. RMG has received grant funding to his institution and ad hoc advisory consultancy honoraria from Viiv. LE has received grant funding to her institution from Merck and honorarium for advisory boards with Gilead, Merck, and Viiv. The authors have no other conflicts of interest to disclose.

Data Sharing

Participants did not provide explicit consent to share their data, and, as this study collected potentially sensitive data, the consent process does not allow data sharing.

Supplemental Material

Supplemental material for this article is available online.

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